Provider Demographics
NPI:1811261506
Name:CONKLIN, NATHANIEL RICHARD (QMHA, CLINICAL COUNS)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:RICHARD
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:QMHA, CLINICAL COUNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CEDAR WAY SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3111
Mailing Address - Country:US
Mailing Address - Phone:503-990-4506
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2684
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:503-238-0769
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORCADCII: 13-12-54101YM0800X
ORCADC II, 13-12-54101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health